Provider Demographics
NPI:1326305814
Name:PROVENCE, MARY ANITA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANITA
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 55107
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-0107
Mailing Address - Country:US
Mailing Address - Phone:317-253-7387
Mailing Address - Fax:317-253-7388
Practice Address - Street 1:5023 E 56TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-1474
Practice Address - Country:US
Practice Address - Phone:317-253-7387
Practice Address - Fax:317-253-7388
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003940A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical